*Note: This article was written in part during the first author s final practicum as a fourth year BScN student (2017). ABSTRACT

Page 1 of 8 DEVELOPING CONFIDENCE FOR PATIENT ADVOCACY: REFLECTIONS FROM AN INTERNATIONAL CLINICAL EXPERIENCE By: Rebecca (Becky) James, BScN,* RN (rjames@ualberta.ca) & Judy E. Mill, RN, PhD Faculty of Nursing, University of Alberta Edmonton, Alberta, Canada *Note: This article was written in part during the first author s final practicum as a fourth year BScN student (2017). ABSTRACT In this article, the first author reflects on the process of developing confidence in selected nursing roles, particularly becoming a strong advocate as a new nurse and communicating effectively with patients and their families. The reflections focus on experiences throughout her four years as an undergraduate nursing student, including a final clinical practicum in Ghana in early 2017. The first author describes this reflective process in first person, while the second author assisted to reflect on and describe aspects of this learning trajectory. This clinical experience in a low income country such as Ghana provided the first author an opportunity to build confidence in her practice and refine her skills as a strong patient advocate. These learning opportunities afforded a better understanding of the relationship between global citizenship and her role as a registered nurse. Key words: Nursing; student; confidence; international; clinical; reflection; Ghana Introduction Advocacy refers to empowering patients in decision making and ensuring that safe and quality care is provided (Choi, 2015, p. 55) and is an important aspect of holistic patient care. Successful patient advocates have strong communication skills and are able to develop positive professional relationships with patients and other health care professionals (Water et al., 2016). The Canadian Nurses Association [CNA] discusses advocacy in the Code of Ethics for Registered Nurses (CNA, 2008). In this document, advocacy is defined as supporting others in speaking for themselves or speaking on behalf of those who cannot speak for themselves (CNA, 2008, p. 22). This code reinforces the need for nurses to have a strong voice to empower their patients to make decisions and to speak for patients who may not have a voice of their own. In addition, the College and Association of Registered Nurses of Alberta [CARNA] (2013) has

R. James & J.E. Mill Page 2 of 8 included patient advocacy in the entry-to-practice competency statement entitled ethical practice. In this competency statement, CARNA (2013) highlights the need for nurses to advocate for safe, competent and ethical care, and reinforces this concept, especially when patients are unable to advocate for themselves. In this situation, it is imperative for the health care team to work together in the best interest of the patient. Some new graduate nurses have reported that continued exposure to collaborative opportunities, such as inter-professional rounds, offers an opportunity to increase confidence within the interdisciplinary team (Pfaff, Baxter, Jack, & Ploeg, 2014). Increased confidence within the health care team promotes the development of quality patient care. Being a confident nurse and a strong patient advocate is essential to ensure that patients are receiving the best care possible and their needs are being fully met. Throughout my nursing program I have worked to develop confidence in the clinical setting, especially when advocating for patients. I ve had several experiences in my clinical education when I ve felt that I needed to be more assertive and confident when speaking to other health care professionals regarding patient care. From February to April 2017, I participated in a 9-week clinical practicum in Ghana, West Africa. During this international clinical experience I became more confident when providing nursing care and, as a result, I know that I will continue to develop confidence as I transition to an independent registered nurse. Throughout this transition, I ve continued to reflect on previous experiences to better understand the development of my confidence. After reviewing the literature, I realized that I am not alone in my struggle to develop confidence as a new registered nurse. Many new nurses have experienced a lack of confidence in their abilities soon after being hired (Pfaff et al., 2014). As well, adjusting to the role of registered nurse is a lengthy process and may take several months to a year (Ortiz, 2015; Pfaff et al., 2014). Confidence, as well as communication skills and educational background, are some of the individual factors that affect new nurses decisions to speak up on behalf of patients (Law & Chan, 2015). Lack of confidence and indecisiveness can negatively impact nursing performance and collaborative practice (Pfaff et al., 2014). Developing confidence and learning to speak up on behalf of patients also leads to better patient experiences and positive outcomes in the work environment. If patients feel that their nurse is confident and competent in what they are doing while advocating for their care, this will lead to increased confidence in the health care system overall, with fewer patients slipping through the cracks. In summary, practicing competently and with confidence is an essential skill that all nurses must develop. Personal Reflection Developing confidence and advocating for patients have been important to me throughout my nursing career. However, both were challenges because I was shy and introverted when I

R. James & J.E. Mill Page 3 of 8 started my nursing program. I enjoyed interacting with peers during class, yet I was nervous to interact with colleagues and other health care professionals during clinical experiences. I felt comfortable communicating with peers and nurses with whom I had a relationship, yet I was often too nervous to ask questions of other nurses or health care team members. Because I was hesitant to speak up, I found it hard to develop confidence. I always felt that becoming confident in practice would be difficult to achieve, but during my clinical experience in Ghana, I became more comfortable asking questions and providing input into patient care. Developing confidence and learning how to be assertive are essential if one is to be a strong patient advocate. When I lacked confidence, it was difficult to advocate for patients even though I felt that I could make an impact on their care. Due to the vulnerability of some patient populations, nurses are in a position that requires them continually to be strong advocates for their patients care (Choi, 2015). Patient advocacy is part of nursing curricula. However, I struggled to understand the concept of advocacy from a textbook. There is evidence in the literature that many nurses are similarly unsure of how to put patient advocacy into practice (Water, Ford, Spence, & Rasmussen, 2016). Several experiences throughout my program have helped to increase my confidence. While performing clinical skills such as medication administration or dressing changes, I ve increased my confidence as I ve had more opportunities to practice. This confidence has come with time and repetition of skills. I ve realized that, in all aspects of life, confidence and comfort increase the more you do something. As a visual learner, I ve also felt more confident attempting skills after I ve watched them being done by an experienced nurse or instructor prior to attempting them. With more experience, I ve also improved my communication skills. Communication is a large component of confidence and assertiveness (Ortiz, 2016). It s hard to be confident and advocate for a patient if you can t clearly communicate with the patient to identify their needs and relay them to the rest of the care team. Through many experiences in the clinical setting, I ve learned to open up and reach out to colleagues and peers, knowing that I could provide a voice to patients who might otherwise not have had their needs met. The confidence I ve gained since the first year of my nursing program developed as a result of having numerous opportunities to practice my skills and build my nursing knowledge. Although I m more confident now, I still feel that as a new registered nurse I will face additional challenges adapting to my new role. Many new graduate nurses have felt a lack of confidence trying to apply knowledge and skills learned in school in the clinical setting (Ortiz, 2016). In my student clinical experiences, I had the opportunity to speak with my instructor or a buddy nurse frequently when making decisions about patient care. I know that I won t be completely on my own as I begin my career, but I still feel there is room to increase my confidence as I transition to being a more independent nurse.

R. James & J.E. Mill Page 4 of 8 During the second year of my nursing degree I became more comfortable in the clinical setting and started to feel like I was coming out of my shell. Regardless, I still needed to push past my comfort level and become a more confident nursing student. I found that being prepared for clinical assignments led to increased confidence throughout the day. I also used strategies such as creating patient timelines to improve time management and reviewing common conditions and medications relevant to the patient population to increase my knowledge and confidence. Despite my intentions, in my third year I still felt like I wasn t as confident in my practice as I should have been, which led to me struggling to find my voice as a patient advocate. During one of my third-year clinical placements, I recall a situation when I did not advocate for my patient in a timely manner. I was bringing pain medications to a post-operative patient who had requested an analgesic. I entered the patient s room, but was interrupted from my task when a physician asked me to retrieve some dressing supplies. Not knowing what to do, I immediately left the room to get the supplies. In this situation, I felt that I wasn t assertive enough and did not tell the physician I had come to provide patient care and could assist him when I was finished. Although I was back in the room within a few minutes, I had felt disappointed in myself that I had not given the analgesic prior to retrieving the dressing supplies, especially as the patient was in pain when I returned to the room. The patient was not upset with me, but I felt as if I had let my patient down by failing to speak up on her behalf. As a result of this experience, I realized I must continue to build my own confidence and work to become a stronger patient advocate in the future. During one of my fourth-year clinical placements, I was able to speak to a physician regarding my patient s care. In this situation, my patient was receiving inadequate pain management and was frustrated that he couldn t get anyone to listen to his concern. I spoke with the resident and physician multiple times to ensure that the care team and patient developed a solution to decrease the patient s pain. I really felt that I had made a difference, and my patient thanked me for listening to his concerns and intervening on his behalf. This positive feedback helped me develop more confidence and become an effective advocate in the clinical setting. In my most recent clinical practice in Ghana, immersed in a new culture and environment, confidence and advocacy became even more critical. To increase my confidence, I looked for opportunities to practice my skills on the clinical units and began to review scholarly articles on confidence development. In the literature, several key themes pertaining to confidence development in graduate nurses were identified: independence, relationship building, receiving positive feedback, and gaining experience (Ortiz, 2016). Being immersed in the Ghanaian culture and learning how to adapt when feeling uncomfortable and overwhelmed helped to make me

R. James & J.E. Mill Page 5 of 8 more confident in my practice. I was able to provide quality nursing care to patients while in an unfamiliar setting with some patients who spoke a different language. My international experience in Ghana helped me feel more confident working in Canada as I transition to my role as a registered nurse. While practicing in the maternity ward and community in Ghana, I worked with similar populations and became more comfortable and confident in my assessment and nursing care of pregnant women and newborns. My international clinical experience was also challenging at times. I strived to become a strong patient advocate, while at the same time learning a new culture and health care system. In many situations I faced barriers, due to either language or cultural differences, when I was unable to truly understand the needs of my patients. I became frustrated when I could not understand what I could do to assist my patients as I tried to navigate these barriers. Because I could not speak the local dialect, I attempted to advocate for needs that were observable, such as asking for privacy, advocating for the proper dressing change procedure, and finding diapers for a neonate whose parents could not afford them. In some cases, I was torn between what I thought I should do on behalf of the patient and what I thought was appropriate in the Ghanaian health care setting. During one shift, for example, I witnessed a distressed mother deliver a still born child. Following the birth, the mother was asked by staff to pay for supplies used during the delivery. This request seemed to be insensitive from my perspective, although I was aware that supplies were often scarce in Ghana. I learned that, even with fee exemptions for maternal care under the Ghanaian National Health Insurance Scheme [NHIS], there were still many costs for new mothers with limited financial resources, such as certain medications and transportation costs not covered under the NHIS (Dixon et al., 2014). Despite the many cultural differences between Canada and Ghana and our different health care systems, this experience helped me to become aware of the importance of advocating for patients. Regardless of the clinical setting, it should be the responsibility of the nurse to advocate for the patient s needs. As strong patient advocates, it is also essential for nurses to consider their potential to influence healthcare at the local and international level. While reflecting on the profound impact of my international experience, I came to realize there was a gap in my knowledge of the relationship between my role as a registered nurse and a global citizen. In addition to providing me with an opportunity to practice as a strong patient advocate, my international clinical experience helped me to understand the importance of practicing as an educated global citizen. As stated by Mill and colleagues (2010), inequities in health exist within and across nations (p. E1). It is one thing to be aware of these inequities, but the authors argue that as professional nurses, we must not only be aware of global challenges, but help contribute to the solution to these challenges.

R. James & J.E. Mill Page 6 of 8 As I continue to reflect on this experience, my desire to contribute to solutions to global challenges has increased. This aspiration has evolved as I become more confident in myself and my practice. Prior to my international experience, I was unsure what it meant to be a global citizen, not unlike other nursing students who have also had difficulty understanding the concept of global citizenship (Burgess, Reimer-Kirkham, & Astle, 2014). I feel privileged to have been able to participate in this global experience and am now starting to connect what I ve learned about global citizenship in the classroom to what I ve seen and experienced in Ghana. Previously I believed that without any international experience, I would not be able to become a proactive global citizen. However, I ve come to realize being a global citizen is possible through participation at the local level and within communities across Canada. Being confident in myself as a registered nurse will help me develop into a stronger global citizen with a sense of global responsibility. I agree with Mill and colleagues (2010) that global responsibility involves becoming aware of issues at the local, national, and international levels and identifying interventions that will positively impact the planet as a whole. By participating in an international experience I ve become more aware of the Canadian social, political, and environmental conditions in which we live and have been able to contrast this with the Ghanaian culture and context, thereby developing a better understanding of the interconnectedness that is so often discussed in reference to global citizenship (Mill et al., 2010). In addition, I have learned that global citizenship also involves developing a sense of compassion that compels one to act on social injustices to create equal and fair opportunities for all (Simpson, Jakubec, Zawaduk & Lyall, 2014). The many differences between Canada and Ghana have prompted me to think about how I can incorporate a global perspective in my own practice when I work as a registered nurse in Canada. Through reflection on experiences like this, I feel better prepared to transition to a competent and independent registered nurse with a global perspective of health. Implications for Future Practice Over the past few years, I have been able to increase my confidence and collaborate with my patients to ensure that I am truly empowering them to be involved in their own care. This transition has been meaningful in my practice as I realize the influence of confidence on patient care and outcomes. My confidence with skills will continue to increase with time, and I know future patients will benefit from my self-reflection as I continue to work towards being an advocate for their care. This professional journey has also benefited my personal life. I feel that I have been able to overcome a sense of shyness and develop strong relationships with peers and colleagues throughout my nursing degree. As I increase my understanding of what it means to become a global citizen, I can incorporate this newly acquired knowledge into my practice,

R. James & J.E. Mill Page 7 of 8 regardless of the setting. While I transition from a nursing student to a registered nurse, I hope to gain insight into the long-term outcomes of being a strong, confident nurse and patient advocate. Conclusion My journey from a first-year student nurse to a registered nurse has involved a significant increase in my confidence and ability to communicate and advocate for patients. Although initially I was unaware of the significance of this journey, I now realize the value of reflecting on my practice and look forward to seeing my growth in the future. I know first-hand the struggles of navigating nursing education with a lack of confidence, and I can strongly emphasize the value of supporting future nurses in their practice as they develop confidence and learn to be stronger patient advocates. I believe that participation in an international clinical experience provides a valuable opportunity for self-growth and learning, and an irreplaceable sense of accomplishment that naturally contributes to the development of confidence. As I reflect on this experience, I know that there will still be situations when I will be nervous and unsure of myself as a novice nurse. However, after reflecting on all the experiences I have had in my nursing education, I know that I have a strong foundation to build upon as I continue to develop my confidence and become a more self-reliant nurse, leader, and patient advocate. References Burgess, C. A., Reimer-Kirkham, S., & Astle, B. (2014). Motivation and international clinical placements: Shifting nursing students to a global citizenship perspective. International Journal of Nursing Education Scholarship, 11(1), 1-8. doi:10.1515/ijnes-2013-0056 Canadian Nurses Association. (2008). Code of ethics for registered nurses. Retrieved from http://cna-aiic.ca/~/media/cna/page-content/pdf-fr/code-of-ethics-for-registerednurses.pdf Choi, P. (2015). Patient advocacy: The role of the nurse. Nursing Standard, 29(41), 52-58. doi:10.7748/ns.29.41.52.e9772 College & Association of Registered Nurses of Alberta. (2013). Entry-to-practice competencies for the registered nurses profession. Retrieved from: http://www.nurses.ab.ca/content/ carna/home/professional-resources/practice-resources/competency-profile.html

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